Effectiveness of endoscopic ultrasound (EUS)-guided choledochoduodenostomy vs. EUS-guided gallbladder drainage for jaundice in patients with malignant distal biliary obstruction after failed endoscopic retrograde cholangiopancreatography: Retrospective, multicenter study (GALLBLADEUS Study).

OBJECTIVES: The aim of this study was to compare endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) vs. EUS-gallbladder drainage (EUS-GBD) in cases of failed endoscopic retrograde cholangiopancreatography (ERCP) for jaundice resulting from malignant distal biliary obstruction (MDBO). METHODS: This multicenter retrospective study included patients with obstructive jaundice secondary to MDBO who underwent EUS-GBD or EUS-CDS with lumen-apposing metal stents after failed ERCP. The primary end-point was clinical success rate. Secondary end-points were technical success, periprocedural adverse events rate (<24 h), late adverse events rate (>24 h), overall survival, and time to recurrent biliary obstruction. RESULTS: A total of 78 patients were included: 41 underwent EUS-GBD and 37 underwent EUS-CDS. MDBO was mainly the result of pancreatic cancer (n = 63/78, 80.7%). Clinical success rate was similar for both procedures: 87.8% for EUS-GBD and 89.2% for EUS-CDS (P = 0.8). Technical success rate was 100% for EUS-GBD and 94.6% for EUS-CDS (P = 0.132). Periprocedural morbidity (<24 h) rates were similar between both groups: 4/41 (9.8%) for EUS-GBD and 5/37 (13.5%) for EUS-CDS (P = 0.368). There was a significantly higher rate of late morbidity (>24 h) among patients in the EUS-CDS group (8/37 [21.6%]) than in the EUS-GBD group (3/41 [7.3%]) (P = 0.042). The median follow-up duration was 4.7 months. Overall survival and time to recurrent biliary obstruction did not significantly differ between the groups. DISCUSSION: After failed ERCP for MDBO, EUS-GBD and EUS-CDS show comparable clinical success rates and technical success. EUS-GBD appears to be a promising alternative for MDBO, even as a second-line treatment after failed ERCP. Further studies are needed to validate these findings and compare the long-term outcomes of EUS-GBD and EUS-CDS.

Management of the Zenker diverticulum: multicenter retrospective comparative study of open surgery and rigid endoscopy versus flexible endoscopy.

BACKGROUND AND STUDY AIM: Zenker's diverticulum is a rare disease that affects quality of life due to dysphagia and regurgitation. This condition can be treated by various surgical or endoscopic methods. PATIENTS AND METHOD: Patients treated for Zenker's diverticulum in three centers in the south of France between 2014 and 2019 were included. The primary objective was clinical efficacy. Secondary objectives were technical success, morbidities, recurrences, and need for a new procedure. RESULTS: One hundred forty-four patients with a total of one hundred sixty-five procedures performed were included. A significant difference was found between the different groups in terms of clinical success (97% for open surgery versus 79% for rigid endoscopy versus 90% for flexible endoscopy, p = 0.009). Technical failure occurred more frequently in the rigid endoscopy group than in the flexible endoscopy and surgical groups (p = 0.014). Median procedure duration, median time to resumption of feeding, and hospital discharge were statistically shorter for endoscopies than for open surgery. On the other hand, more recurrences occurred in patients treated by endoscopy than those treated by surgery, and more reinterventions were required. CONCLUSION: Flexible endoscopy appears to be as effective and safe as open surgery in the treatment of Zenker's diverticulum. Endoscopy allows a shorter hospital stay at the expense of a higher risk of recurrence of symptoms. It could be used as an alternative to open surgery for the treatment of Zenker's diverticulum, especially in frail patients.

Echocardiographic hemodynamic assessment in decompensated cirrhosis: comparison between Intensivists and Gastroenterologists.

BACKGROUND & AIMS: Ascites is a frequent complication of cirrhosis. In intensive care units, initial hemodynamic assessment is frequently performed by echocardiography. This study evaluated the feasibility and usefulness of early hemodynamic assessment in the gastroenterology ward. METHODS: This observational cohort study prospectively included all patients admitted to a teaching hospital's gastroenterology unit for decompensated cirrhosis. A gastroenterologist with minimal training and an intensivist both performed an echocardiography exam. The primary outcome was inter-rater agreement and reliability for three echocardiography parameters: visual LVEF (Left Ventricular Ejection Fraction), subaortic VTI (velocity time integral) and E wave velocity. Secondary outcomes were agreement for presence of pleural effusion, description of 3 hemodynamics profiles (hypovolemic, hyperkinetic and intermediate), and 28-day mortality. RESULTS: From March 2018 to March 2020, 53 patients were included. The median age was 62 years and 81% were men. Patients presented mostly advanced liver disease, with 43% Child-Pugh C and median MELD score of 15.2. The limits of agreement between intensivists and gastroenterologists for subaortic VTI were - 6.6 to 7.2 cm, and ranged from - 0.6 to 0.37 m.s-1 for E wave velocity. Clinically significant differences between intensivists and gastroenterologists were found in 22% for subaortic VTI and 24.5% for E wave velocity. Reliability was good for subaortic VTI (ICC: 0.79, 95% CI [0.58; 0.9;]) and moderate for E wave velocity (0.53, 95% CI [0.19; 0.74]). The three hemodynamics profiles had different prognosis, with a 28-day mortality for Hypovolemic, Intermediate and Hyperkinetic group of 31, 18, and 4%, respectively. CONCLUSION: Reliability of hemodynamic assessment by gastroenterologists was good, while agreement was unsatisfactory, advocating for further training. Transthoracic echocardiography can differentiate hypovolemia from hyperkinetic states. The role of transthoracic echocardiography in managing decompensated cirrhosis requires further study. CLINICAL TRIAL NUMBER: NCT03650660.

Impact of Gastric Electrical Stimulation on Economic Burden of Refractory Vomiting: A French Nationwide Multicentre Study.

BACKGROUND & AIMS: Medico-economic data of patients suffering from chronic nausea and vomiting are lacking. In these patients, gastric electrical stimulation (GES) is an effective, but costly treatment. The aim of this study was to assess the efficacy, safety and medico-economic impact of Enterra therapy in patients with chronic medically refractory nausea and vomiting. METHODS: Data were collected prospectively from patients with medically refractory nausea and/or vomiting, implanted with an Enterra device and followed for two years. Gastrointestinal quality of life index (GIQLI) score, vomiting frequency, nutritional status and safety were evaluated. Direct and indirect expenditure data were prospectively collected in diaries. RESULTS: Complete clinical data were available for142 patients (60 diabetic, 82 non-diabetic) and medico-economic data were available for 96 patients (36 diabetic, 60 non-diabetic), 24 months after implantation. GIQLI score increased by 12.1 ± 25.0 points (p < .001), with a more significant improvement in non-diabetic than in diabetic patients (+15.8 ± 25.0 points, p < .001 versus 7.3 ± 24.5 points, p = .027, respectively). The proportion of patients vomiting less than once per month increased by 25.5% (p < .001). Hospitalisations, time off work and transport were the main sources of costs. Enterra therapy decreased mean overall healthcare costs from 8873 US$ to 5525 US$ /patient/year (p = .001), representing a saving of 3348 US$ per patient and per year. Savings were greater for diabetic patients (4096 US$ /patient/year) than for non-diabetic patients (2900 US$ /patient/year). CONCLUSIONS: Enterra therapy is an effective, safe and cost-effective option for patients with refractory nausea and vomiting. CLINICALTRIALS: gov Identifier: NCT00903799.

Gastric Electrical Stimulation Reduces Refractory Vomiting in a Randomized Crossover Trial.

BACKGROUND & AIMS: There have been conflicting results from trials of gastric electrical stimulation (GES) for treatment of refractory vomiting, associated or not with gastroparesis. We performed a large, multicenter, randomized, double-blind trial with crossover to study the efficacy of GES in patients with refractory vomiting, with or without gastroparesis. METHODS: For 4 months, we assessed symptoms in 172 patients (66% women; mean age ± standard deviation, 45 ± 12 years; 133 with gastroparesis) with chronic (>12 months) of refractory vomiting (idiopathic, associated with a type 1 or 2 diabetes, or postsurgical). A GES device was implanted and left unactivated until patients were randomly assigned, in a double-blind manner, to groups that received 4 months of stimulation parameters (14 Hz, 5 mA, pulses of 330 µs) or no stimulation (control); 149 patients then crossed over to the other group for 4 months. Patients were examined at the end of each 4-month period (at 5 and 9 months after implantation). Primary endpoints were vomiting score, ranging from 0 (daily vomiting) to 4 (no vomiting), and the quality of life, assessed by the Gastrointestinal Quality of Life Index scoring system. Secondary endpoints were changes in other digestive symptoms, nutritional status, gastric emptying, and control of diabetes. RESULTS: During both phases of the crossover study, vomiting scores were higher in the group with the device on (median score, 2) than the control group (median score, 1; P < .001), in diabetic and nondiabetic patients. Vomiting scores increased significantly when the device was ON in patients with delayed (P < .01) or normal gastric emptying (P = .05). Gastric emptying was not accelerated during the ON period compared with the OFF period. Having the GES turned on was not associated with increased quality of life. CONCLUSIONS: In a randomized crossover study, we found that GES reduced the frequency of refractory vomiting in patients with and without diabetes, although it did not accelerate gastric emptying or increase of quality of life. Clinicaltrials.gov, Number: NCT00903799.

Perineal descent predicted by a pelvic bone factor: the pelvic incidence angle.

PURPOSE: By measuring the pelvic incidence angle, we assessed the relationship between pelvic floor disorders and pelvic morphology, which allowed us to document for the first time the hypothesis that pelvic incidence may be a predictive factor of perineal descent. METHODS: In a retrospective study of 197 women, the perineal descent at rest and during straining was assessed by defecography. The pelvic incidence angle (53 degrees +/- 9 degrees , independent of the subject position) was defined as the angle between the line perpendicular to the sacral plate at its midpoint and the line connecting this point to the middle of the femoral heads axis. The pelvic incidence angle was correlated with the incidence of pelvic floor descent. RESULTS: In those with pelvic floor descent at rest compared with those without, pelvic incidence angle was significantly larger (64 degrees vs. 53 degrees , P < 10E-06). As a predictive factor of perineal descent at rest, a great pelvic incidence (>62 degrees ) had a sensitivity (73 percent), specificity (82 percent), positive predictive value (81 percent), and negative predictive value (75 percent). CONCLUSIONS: A large pelvic incidence (>62 degrees ) may be a predictive factor of perineal descent at rest before the apparition of other acquired factors. With pelvic incidence >62 degrees , a large overhang between the insertions increases the strains on the perineum, which is rather horizontal.

Global sequencing approach for characterizing the molecular background of hereditary iron disorders.

BACKGROUND: New genetic forms of hereditary hemochromatosis (HH) or hereditary hyperferritinemia (HF) have been identified over the last few years, and abnormalities of various genes may interact in a single patient. This study aimed to develop a rapid automated method for sequencing the main genes involved. METHODS: We used a standard 96-well microplate with a single PCR condition in an adaptation of the SCAIP (single-condition amplification with internal primer) method to sequence the HFE (hemochromatosis), HAMP (hepcidin antimicrobial peptide), HFE2/HJV [hemochromatosis type 2 (juvenile)], SLC40A1 (ferroportin), and TFR2 (transferrin receptor 2) genes, and the 5' untranslated region of the FTL (ferritin, light polypeptide) gene. To further simplify the method, we adjusted PCR conditions to avoid the use of an internal primer and applied this single-condition amplification method to 38 selected, unrelated patients. We tailored the genetic investigation according to the clinical picture, with the patients falling into 2 groups. Group 1 consisted of patients with hyperferritinemia and high transferrin saturation (TS) (classic adult and juvenile HH forms, groups 1A and 1B, respectively), and group 2 consisted of patients with hyperferritinemia and low, typical, or slightly increased TS, with or without iron overload (groups 2A and 2B, respectively). RESULTS: With this strategy we identified single-gene and multigene abnormalities, including 6 previously undescribed abnormalities in HFE (c.794dupA), HFE2 (c.-89-4dupT), and SLC40A1 (c.262A>G, c.533G>A, c.1468G>A, and c.-59_-45del). CONCLUSION: This method is a simple approach for investigating hereditary iron overload or HF and allows rapid evaluation of patients.

Infectious complications, prognostic factors and assessment of anti-infectious management of 212 consecutive patients with acute pancreatitis.

AIM: Acute pancreatitis is an important cause of morbidity and mortality, mainly due to sepsis. The aim of this study was to determine the incidence of infectious complications and their impact on mortality in patients hospitalized for acute pancreatitis. PATIENTS AND METHODS: Patients admitted for acute pancreatitis were retrospectively included within a period between 1995 and 2000. Incidence of abdominal and extra-abdominal sepsis and specific care were specifically analyzed. Risk factors for death were evaluated by uni- and multivariated analysis. RESULTS: Two hundreds and twelve consecutive patients (128 males, median age 54 years) were included. Mortality was 10.8%. At least one infectious episode was collected in 25% of the patients with an abdominal sepsis (26.8%), bacteriemia (24.4%), respiratory (24.4%) and urinary tracts (19.5%) infections. Infection was polymicrobial in 37.5%. An antibiotic prophylaxis was administered in 10.8%, more often in patients with severe pancreatitis. It did not alter mortality or incidence of infections but significantly delayed occurrence of sepsis. Mortality of patients treated with more than one line of antibiotics was higher. However in this study infectious complications were not an independent factor for mortality. CONCLUSION: Infections are frequent and polymicrobial but are not an independent prognostic factor during acute pancreatitis.

Patient information for liver biopsy: impact of a video movie.

AIMS: The information given to patients before a medical procedure is usually delivered verbally and in the form of a written document. Viewing a video movie about the procedure might be helpful in improving the quality of patient information and thus contributed to reduce patient anxiety. The aim of this prospective study on the methods used to deliver information to patients scheduled for liver biopsy was to determine, in comparison with standard information delivery, the impact on anxiety and understanding of additional information provided by a video movie. METHODS: Patients included in this study were scheduled for liver biopsy. Three days before the procedure, a physician informed the patients about liver biopsy and gave them a written information document. After this standard information delivery, the patients were randomly assigned to two groups, to view or not a video movie illustrating liver biopsy and recalling the information provided in the information document. Anxiety was measured after the information visit and just before the biopsy procedure using Spielberger's self-administered STAI-Y questionnaire. Patient understanding of and satisfaction with the information received were evaluated respectively before and after the procedure. RESULTS: Among the 67 patients retained for analysis, 33 viewed the information video and 34 did not. The level of anxiety measured at the information visit and before liver biopsy was similar in the two groups (38.8 and 37.4 with video versus 38.9 and 40.1 without video). The patients had an excellent understanding of the information received (12.3/14 with video; 12.7/14 without video) and were well satisfied with the information received. CONCLUSION: The patients understood and were well satisfied with the information received about liver biopsy. Complementary information in the form of a video movie had no effect on patient anxiety.

Esophageal pH-impedance monitoring and symptom analysis in GERD: a study in patients off and on therapy.

INTRODUCTION: Combined esophageal pH-impedance monitoring allows detection of nearly all gastroesophageal reflux episodes, acid as well as nonacid. However, the role of nonacid reflux in the pathogenesis of symptoms is poorly known. The aim of this study was to evaluate the diagnostic yield of this technique in patients with suspected reflux symptoms while on or off PPI therapy. PATIENTS AND METHODS: The recordings of 150 patients recruited at seven academic centers with symptoms possibly related to gastroesophageal reflux were analyzed. Reflux events were detected visually using impedance (Sandhill, CO) and then characterized by pHmetry as acid or nonacid reflux. The temporal relationship between symptoms and reflux episodes was analyzed: a symptom association probability (SAP) > or =95% was considered indicative of a positive association. RESULTS: One hundred fifty patients were included, 102 women (mean age 52 +/- 14 yr, range 16-84). Among the 79 patients off PPI, five did not report any symptom during the recording period. A positive SAP was found in 41 of the 74 symptomatic patients (55.4%), including acid reflux in 23 (31.1%), nonacid reflux in three (4.1%), and acid and nonacid in 15 (20.3%). In the group of patients on PPI (N = 71, 46 women, mean age 51 +/- 15 yr), 11 were asymptomatic during the study, SAP was positive in 22 of the 60 symptomatic patients (36.7%), including acid reflux in three (5.0%), nonacid reflux in 10 (16.7%), and acid and nonacid in nine (15.0%). The symptoms most frequently associated with nonacid reflux were regurgitation and cough. CONCLUSION: Adding impedance to pH monitoring improves the diagnostic yield and allows better symptom analysis than pHmetry alone, mainly in patients on PPI therapy. The impact of this improved diagnostic value on gastroesophageal reflux disease management remains to be investigated by outcome studies.

Initial endoscopic description of esophageal squamous cell carcinomas.

INTRODUCTION: The aim of this study was to evaluate initial endoscopic practices at diagnosis of esophageal squamous cell carcinoma in comparison with current recommendations. We wanted to develop a standard model for the endoscopy report which could be used in routine practice. PATIENTS AND METHODS: From January 2000 to December 2002, 122 patients were hospitalized for esophageal squamous cell carcinoma. The initial endoscopic reports were reviewed retrospectively and compared with a model report established on the basis of current recommendations. RESULTS: One hundred and nineteen reports were re-examined. The principal reason for performing the endoscopic examination was dysphagia in 73.9% of patients. Tumor measurements (height, upper and lower extremities) were recorded in 51.2%, 79% and 41% of reports, respectively. 14.4% of the analyzed reports concerned endoscopic procedures which were performed after a first endoscopic examination because the initial report provided an imprecise tumor description. Tissue samples taken during the initial endoscopy allowed a pathological diagnosis in 94.2% of patients. Lugol staining was performed in 2.5% of procedures. CONCLUSION: Insufficiently rigorous reporting compromises the reliability of initial upper digestive endoscopic procedures. Application of a standardized model for routine practice would favor more complete reports, starting with the first procedure.

Effect of champagne compared to still white wine on peripheral neurotransmitter concentrations.

To evaluate how the peripheral release of neurotransmitters such as serotonin, dopamine, cholecystokinin, and beta-endorphin is involved in drinking behavior, blood concentrations of these neurotransmitters were followed in 40 healthy young volunteers during the first hour after ingestion of a moderate dose of some common alcoholic beverages (champagne, still white wine) as compared to water. Concerning serotonin levels, two groups of subjects are statistically distinct: one with low basal serotonin levels (< 620 nmol/L) which responded with an increase in serotonin (52% in 10 minutes), and a second group with higher basal serotonin levels (> 620 nmol/L) which responded with a decrease ( 190% in 60 minutes). Variations in serotonin concentrations appear to depend upon the alcoholic content of the beverage. A rapid increase in plasma dopamine concentrations after consumption of champagne seems to be due to the nonalcoholic content of the beverage. Cholecystokinin values were not significantly different between the three beverages: the observed increase can be explained by a moderate gastric distention. Beta-endorphin levels didn't change significantly after drinking. In conclusion, some significant blood variations of serotonin and dopamine appeared even after moderately dose of champagne or still white wine. These changes might be partially responsible for the different drinking behavior.

Relapsing cardial stenosis after laparoscopic nissen treated by esophageal stenting.

Dysphagia after antireflux surgery is often a challenging situation. We report the case of a patient with relapsing cardial stricture and a weight loss of 24 kg following a laparoscopic Nissen procedure. Initial presentation was consistent with the diagnosis of pseudoachalasia and was resistant to endoscopic dilatation. Dysphagia was relieved by surgery, which showed cardial strangulation by tightly sutured diaphragmatic pillars. Symptoms and cardial stricture relapsed after a few months with no significant relief after repeated dilatations. Conservative treatment by endoscopic transcardial prosthesis for six weeks allowed a return to normal diet and a weight gain of 10 kg within a 30-month followup period.

[Effect of assisted ventilation and position on gastro-esophageal acid reflux after laparotomy]. / Effet de la ventilation assistée et de la position sur le reflux gastro-oesophagien acide après laparotomie.

AIMS: Gastro-esophageal reflux disease (GERD) is frequent in mechanically ventilated patients, often source of hemorragic or respiratory complications. The aim of this study was to determine promoting factors for acid reflux and to define the role of methods of ventilation and body position on reflux. METHODS: Fifteen patients with no history of GERD were included, following scheduled abdominal surgery. Reflux was measured in the proximal and distal esophagus by pH-metry. Events associated with reflux were detected by a videocamera linked to a videocassette recorder synchronized to the pH data logger. Position of the patients was randomized between supine and recumbent 30 degrees. Patients were first placed on mechanical ventilation then breathed spontaneously, determining 2 periods of equal duration during which provocative maneuvers were carried out. RESULTS: Acid reflux was absent in recumbent 30 degrees posture. Acid contact time and number of reflux in supine posture were 0.5 +/- 0.4% and 0.3 +/- 0.2/h respectively with mechanical ventilation and 4 +/- 2.5% and 1 +/- 0.5/h respectively with spontaneous breathing (P<0.05 vs position 30 degrees ) in distal esophagus. Twenty-five% of reflux episodes were associated with an event, mainly cough. CONCLUSION: Acid reflux is rare immediately following laparotomy. Seventy-five per cent of reflux occurred without any detectable event. Reflux was absent in semi recumbency. Mechanical ventilation did not facilitate reflux.

Patterns of esophageal inhibition during swallowing, pharyngeal stimulation, and transient LES relaxation. Lower esophageal sphincter.

Lower esophageal sphincter (LES) relaxation and esophageal body inhibition co-occur during esophageal peristalsis but not necessarily during pharyngeal stimulation or transient LES relaxation (tLESR). This study examined these relationships and the impact on reflux. Nine young volunteers were studied. An artificial high-pressure zone (HPZ) was established, and pH was recorded 8 and 5 cm proximal to the LES. Pharyngeal stimulation was by water injection and gastric distension with liquid or gas. Peristalsis, pharyngeal stimulation, and spontaneous events were recorded. Swallowing relaxed the LES in 100% of trials (the HPZ in 80%) and caused no reflux. Pharyngeal stimulation relaxed the LES in two-thirds of trials, had no effect on the HPZ, and caused no reflux. Gastric distension was associated with 117 tLESRs, 48% with acid reflux, and 32% with gas reflux; there was no effect on the HPZ. We conclude that LES relaxation is a necessary but not sufficient condition for reflux. LES relaxation and esophageal body inhibition are independent events that may be concurrent (swallowing) or dissociated (tLESR).